Acad Psychiatry (2014) 38:639–646 DOI 10.1007/s40596-014-0160-5
COLUMN: EDUCATIONAL RESOURCE
Violence Prevention Education Program for Psychiatric Outpatient Departments Robert E. Feinstein
Received: 29 December 2013 / Accepted: 2 May 2014 / Published online: 25 July 2014 # Academic Psychiatry 2014
Abstract Objective Approximately 40 % of psychiatrists and up to 64 % of psychiatric residents have been physically assaulted. Ranges of 72–96 % of psychiatric residents in various studies have been verbally threatened. As violence risk occurs in outpatient settings, our department developed a quality and safety curriculum designed to prepare psychiatric residents and staff to optimally respond to aggressive outpatients and violence threats or events. Methods In 2011 and 2012, we offered an 8-part violence prevention performance improvement curriculum/program including (1) situational awareness/creating a safe environment; (2) violence de-escalation training; (3) violence risk assessment training, use of risk assessment tools, and medical record documentation; (4) violence safety discharge planning; (5) legal issues and violence; (6) “shots fired on campus” video/ discussion; (7) “2011 violence threat simulation” video/ discussion; and (8) violence threat simulation exercise. This program was offered to approximately 60 psychiatric residents/staff in each year. Results We obtained qualitative comments about the entire program and data from 2 years of post-event surveys on the usefulness of the “violence threat simulation exercise.” The large majority of comments about program elements 1 to 7 were positive. In 2011 and 2012, respectively, 76 and 86 % of participants responded to a post-event survey of the violence threat simulation exercise; 90 and 88 % of participants, respectively, reported the simulation to be very helpful/
Electronic supplementary material The online version of this article (doi:10.1007/s40596-014-0160-5) contains supplementary material, which is available to authorized users. R. E. Feinstein (*) Department of Psychiatry, Colorado School of Medicine, Aurora, CO, USA e-mail: [email protected]
somewhat helpful; and 86 and 82 % of participants, respectively, reported feeling much better/better prepared to deal with a violent event. Although some participants experienced anxiety, sleep disturbances, increase in work safety concerns, and/or traumatic memories, the majority reported no post-simulation symptoms (72 and 80 %, respectively). Conclusions Although we are unable to demonstrate that this program effectively prevents violence, the overall positive response from participants encourages us to continue developing our quality and safety program and to offer our easily reproducible and modifiable curriculum to others.
Keywords Curriculum development . Violence prevention education and training
The need to prevent violent occurrences in outpatient psychiatric settings is a largely under-recognized problem. In a recent review [1], 100 % of nurses and 24–57 % of physicians in general hospital settings, as documented in multiple studies [1], were annually experiencing aggression or violence from patients. Of all health care workers, 9–25 % as documented in multiple studies [1] experienced verbal aggression. The average rate of reported assault of surveyed psychiatrists is 40 % [2]. The range of percentage of psychiatric residents who report physical assaults is 19–64 % as documented in multiple studies [2]. Multiple studies [1] also show ranges of 72–96 % of residents who have been verbally threatened. Threats, aggression, and violence most frequently occur in high volume patient areas, such as emergency rooms, psychiatric services, geriatric services, and hospital waiting areas [3]. According to University of Colorado Police data, 10 deaths/hostage situations occurred in our state’s health-care facilities between 1987 and 2012. In 2011 and 2012, two serious violent threat
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situations occurred in our own outpatient department that has led to temporary closures of the clinic. While residency training programs provide lectures and training in limited aspects of violence prevention, few offer a comprehensive educational approach for an outpatient setting. This paper describes a unique quality and safety performance and improvement violence prevention curriculum/ program designed for psychiatric residents, staff, and faculty. The Quality Projects Review Board of the Colorado School of Medicine and our Maintenance of Certification Portfolio Approval Program (MOCPAP) have accepted this curriculum/ program as both a quality and safety project and a Maintenance of Certification Part IV Program.
Methods In 2011–2012, we developed and implemented an 8-part outpatient violence prevention curriculum/program for psychiatric residents, staff, and faculty. This quality and safety performance improvement project was developed after several years during which our outpatient clinicians were being threatened by aggressive patients. We have delivered this curriculum/program in 11 h of seminars, which are casebased, interactive, practical experiential, and utilize scenariobased training. See Table 1 for a summary of the curriculum and methods used for teaching. Situation Awareness/Creating a Safe Environment (1-h Session) Conducted in a classroom, and then followed by a walkthrough of our outpatient department, the session covers two elements: (1) Review of the safety features in the outpatient environment. This consists of (a) teaching the use of waiting room and semiprivate interviewing spaces as initial locations for screening potentially intoxicated or violent patients; (b) observe the safety setups required for each resident’s office; (c) walk traffic paths to all exits; and (d) demonstrate use of hallway and office panic buttons, the public address system, and the use of our video surveillance system. We test residents on their ability to describe the exact location of their offices (the first piece of critical information needed when calling for help); (2) Review of outpatient emergency communication plans. This component requires all residents and staff to (a) enroll in our system to receive mass emergency communication alerts via cell phones and e-mails; (b) programming emergency police/security phone numbers into speed dials on their cell/office phones; and (c) receive and study our communication plans, call down list, and summary of this plan on our emergency preparedness information cards, which must be attached to each person’s photo identification card.
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Violence De-escalation Training (1-h Session) Many residency programs offer training on verbal deescalation techniques (e.g., those disseminated by the Crisis Prevention Institute [4]). Since using external resources for trainings can be expensive and time consuming, we developed a 1-h class utilizing role-plays and videos, during which residents practice recognition and interventions for six phases of a violent episode as detailed elsewhere [5–7]. A review of these six phases is also available in supplementary online materials. Violence Risk Assessment Training, Use of Risk Assessment Tools, and Medical Record Documentation (1-h Session) This case-based teaching session focuses on four topics: (1) guidelines for interviewing a violent patient, (see Table 2); (2) clinical assessment of violence risk [8]; and (3) use of violence risk assessment tools (see Tables 3 and 4) practice documenting violence risk. Violence prevention interviewing and history taking are accomplished through case-based teaching and is described elsewhere [6, 7]. We emphasize and practice with a case, using a clinical assessment of imminent violence risk [6–8] which includes (a) clinical assessment of current violent ideation, (b) recent and past history of violence, (c) comorbid medical/psychiatric conditions associated with violence, (d) current and past substance use, (e) assessment of the patient’s support network, (f) assessing the patient’s ability to cooperate with current and proposed treatment, and (g) subjective responses to the interview [6–8]. While clinical assessment of violence risk is essential, judgments of risk can be systematized and enhanced by utilizing standardized violence risk assessment tools, which, by promoting thoroughness, offer better opportunities for improving outcomes. Use of risk assessment tools also serve as part of a mitigating strategy against malpractice lawsuits. Via case-based teaching, clinicians practice the use of the violence and suicide assessment scale (VASA) [9] and the modified overt aggression scale (MOAS) [10]. They learn how to use these tools and document their results in our electronic health record (EHR). We also review the use of other standardized violence risk assessment scales as described in Table 3. Outpatient residents are required to use a risk assessment tool on all intakes and whenever the specter of potential violence has been raised. Violence Safety Discharge Planning (1-h Session) Effective discharge planning from the hospital, emergency departments, or outpatient clinics leads to lower readmission rates for psychiatric patients [11–13]. To
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Table 1 Summary of eight modules and core teachings methods Pretest of all eight modules (see online supplemental materials) I. Situational awareness/creating a safe environment ❖ Each staff member must be able to describe the exact location of his/her office. ❖ Organize an all-staff clinic walk-through to discuss the outpatient environment including the following: • Use the waiting room and semiprivate interviewing spaces, safety of clinic offices, location of all exits, review use of panic buttons, public address system, and video surveillance system ❖ Implement outpatient communication plan • Enroll in a mass communication system for emergency alerts • All should program security/police on office/cell phone speed dials • Review use of the event leadership team and the call down list • Review use of call-in information line • Review evacuation plan • Review what to do in event of an active shooter situation • Review/attach emergency preparedness card information to photo ID II. Violence de-escalation training ❖ Teach six phases of a violent episode: (1) observation, (2) psychomotor, (3) early verbal, (4) late verbal phases, (5) violent episode, and (6) post-violent episode and relevant verbal interventions for each of the phases. Pedagogy: mini-lecture, role-plays, and videos III. Violence risk assessment training, use of risk assessment tools, and medical record documentation ❖ Discuss guidelines for interviewing a violent patient (Table 1), 10-part clinical assessment of violence risk, use of VASA and MOAS ❖ Practice documentation of violence risk and use of risk assessment tools in the electronic health record (EHR) Pedagogy: mini-lecture, case-based teaching. EHR demonstration and practice IV. Violence safety discharge planning checklist ❖ Review the elements of safety discharge planning Pedagogy: case-based teaching, use the safety discharge checklist (Table 3) V. Legal issues and violence ❖ Discuss/review Tarasoff 1 and 2, relevant state laws, confidentiality/HIPPA laws, laws for voluntary/involuntary commitment Pedagogy: mini-lecture, case-based teaching VI. “Shots fired on campus” video/discussion ❖ Show video and discuss/review the safety strategies of getting out, sheltering in, helping others, and taking out an active shooter Pedagogy: video education, mini-lecture, group discussion VII. 2011 Violence threat simulation video/discussion ❖ Show 15-min video of a prior threat simulation exercise as stimulus for discussion of the benefits and risks, and used as an opportunity to obtain voluntarily consent to participate in an upcoming live simulation Pedagogy: video education, mini-lecture, group discussion VIII. Violence threat simulation exercise ❖ This 4-h experiential simulated violence threat exercise includes (1) review of the safety rules for the exercise, (2) verbally administer a group quiz reviewing all of the prior seven elements of this program, and (3) participation in two or three different simulation exercises and debriefings and summarize what was learned Pedagogy: group quiz, experiential learning, group discussion, min-lectures Posttest of all eight modules (see online supplementary materials)
facilitate patient connections to needed outpatient services and mitigate re-occurrence of violence after discharge, we use a single case-based teaching session, in which residents roleplay a case using our standardized violence dischargeplanning checklist (see Table 4). Residents are expected to use this checklist with at least one appropriate patient during the first month of their outpatient rotation.
Legal Issues and Violence (1-h Session) Through case-based teaching we review Tarasoff 1 and 2 [14], our own state laws for “duty to warn” and “duty to protect,” our state commitment laws, and confidentiality requirements when working with violent patients including the Health Insurance Portability Act (HIPPA) exemption rule [15].
642 Table 2 Guidelines for interviewing a violent patient • Interview angry or violent patients in a safe environment • Staff, security, or police should be nearby to intervene, as needed • Establish a working alliance in an effort to better enable patient to accept help and begin finding alternative solutions to hurting others • Focus on recent crisis (e.g., “Why do you think you’re feeling angry/ violent now?) • Identify stressor(s) that have immediately precipitated aggressive/ violent symptoms • Explore the meaning of present violent symptoms and how they’ve evolved over the past 6 weeks • Develop the time line of recent events contributing to the violence • Explore the relationship between past violence and present symptoms • Address patient’s efforts to minimize their difficulties and obscure their intentions • Obtain collateral information from family, friends and the treating providers, past medical records, police, etc. • Monitor common reactions (counter-transferences) to violent patients who are affecting your judgments • Direct the focus of the interview toward risk assessment, treatment, and prevention
“Shots Fired on Campus” Video/Discussion (1-h Session) Jointly taught by police and faculty, residents view and discuss a 15-min video, “Shots Fired on Campus” [16], which depicts what to do in case of a shooter or hostage situation. The video emphasizes how to “get out, shelter in, help out, or take out” an active shooter. We also review previous incidents that occurred in our outpatient clinic.
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with adults, (e) hostage situation with children, and (f) bomb threat. (See supplementary materials we use for the development of these simulations.) These simulated exercises provide experiential training for residents, faculty, staff, and police and are held during a time when the outpatient clinic is closed. We use actors, volunteers, and police to stage and execute three different scenarios per year. Our annual groups of approximately 60 participants have no prior knowledge of the scenarios they will encounter. The exercise has two parts:
Part 1: Safety Review/Violence Prevention Quiz (1-h) We begin with a lunch orientation, where participants register and don appropriately colored T-shirts, identifying them in the simulation either as patients, families, observers, or police. We utilize actor(s) role playing patient/family members, police actors playing patients or assailants, and members of the University Police force who participate in this exercise for their own training. The police review the safety rules of the simulation and emphasize the “absolutely no physical contact rule.” Faculty administers a 35-min group quiz (see supplementary materials) reviewing material previously taught over the entire 7-h prevention program.
Part 2: Three 1-h Simulation Exercise (20–30-min Scenarios and 30–45-min Debriefings)
Violence Threat Simulation Exercise (4 h or ½day of Clinic Time)
Our scenarios are designed to involve multiple participants as in real-life group occurrences. They test participants’ abilities to manage aggressive patients and violent events and test the capabilities of our threat leadership team and the effectiveness of our communication and evacuation plans. Participants receive mass emergency alerts with directions about the simulated threat and are obliged to form a leadership team to manage the event. Some gain experience utilizing our safety systems (e.g., panic buttons, public address system, video surveillance, working with police). Participants may manage a threatening/aggressive/or violent patient, or an agitated family, while others may help or evacuate injured/disabled patients, or manage children/families attending our clinic.
This violence threat simulation exercise has been an annual event since 2011. Faculty and our University Police Preparedness Group jointly plan, deliver, and assess each annual event. To date, we have developed and utilized six different scenarios: (a) distant telephone threat, (b) a patient verbally escalating toward violence, (c) active shooter, (d) hostage situation
The Debriefings After each scenario, the police and faculty co-facilitate a 30–45-min large group debriefing and discussion, which we video. We review what happened during each scenario and learn what did and did not work. We compile a list of problematic processes or safety concerns for future amelioration.
2011 Violence Threat Simulation Video/Discussion (1-h Session) Residents view and discuss a 15-min video we made of the 2011 violence threat simulation exercise. We discuss (a) the intensity and realism of a simulated exercise, (b) the benefits of the program and the risks of developing traumatic symptoms, and (c) ask residents/staff to sign a voluntary consent to participate in an upcoming simulation.
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Table 3 Violence risk assessment tools Risk assessment tools
Patient population
Identifies risk factors
Measures risk factors
Combines risk factor
Produces a final violence risk estimate
Clinical judgments for violence Standard list of violence risk factors Historical clinical risk (HCR-20) [18]
All All Clinician administered general psychiatric patients Clinician administered acute psychiatric patients (C0VR) offenders (LSI)
Some Yes Yes
No No Yes
Yes No No
No No No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Classification of violence risk (COVR) [19] Level of service inventory (LSI) [18] Violence risk appraisal guide [20] Violence and suicide assessment scale (VASA) [9]
Clinician administered mentally Il offenders forensic Clinician administered general psychiatric patients
Post-Simulation Follow-up Several days after the violence threat simulation exercise, we release an online post-event survey, available for 10 days, to determine the usefulness of the simulation. One month later, the police and outpatient leadership analyze these results together, with the addition of written recommendations prepared by our Police Emergency Preparedness Group.
numbers into their cells phones during or immediately after the simulated exercise. Several residents commented they had little prior knowledge of violence risk assessment tools (see Table 3). No residents reported knowing how to use the modified overt aggression scale (MOAS) or the violence and suicide assessment scale (VASA) already available in our EHR. Residents were aware of confidentiality requirements if a danger to self/others existed but were not aware of the Health Insurance Portability and Accountability Act Exemption
Results In 2011 and 2012, we collected qualitative comments and some quantitative data from diverse sources including our residency course evaluation forms, direct participant questioning, and review of comments made when sessions were recorded by video. The author combined and sorted 51 qualitative comments into three groups: positive, neutral, and negative comments. Examples of the most positive and most negative comments and useful neutral comments are presented in Table 5. We also collected qualitative and quantitative data from an online survey evaluating the violence threat simulation exercise. One week after completion of all seven-curriculum components (excluding the violence threat simulation exercise), we checked the electronic registry for mass communications to see how many residents had signed up to receive emergency alerts. Approximately half of the residents were registered to receive alerts. Via direct questioning of a total of 2 years of 127 participants (at the check-in for the simulated exercises during 2011 and 2012), we determined that approximately 2/3 of the participants had not programmed emergency police/ security telephone numbers into the speed dials on their cell phones. One week after the violence threat simulation exercise, we again checked the registry and queried each resident. We found that 100 % of residents had enrolled in mass communication alerts and had programmed emergency phone
Table 4 Violence safety discharge checklist Prior to discharge ☐ Make sure the patient’s immediate discharge environment is safe, without weapons or other means to hurt others ☐ Review with the patient any current/new stressors that might precipitate violence ☐ Review possible early warning signs of increasing violence risk (e.g., substance use or isolation etc.) ☐ Review the patient’s coping strategies to diffuse their dangerous impulses (e.g., use of relaxation techniques, exercise, distraction, etc.) ☐ Review all members of the patient’s support network (e.g., friends, family, place of worship, etc.) and relevant contact information of people the patient can call for help. ☐ Review the use of a 24-hour crisis hotline ☐ Review the use of medications to control violent symptoms ☐ Review the needs and detailed arrangements for follow-up care including the contact information of specific mental health professionals or programs (e.g., alcoholic anonymous) to be contacted for treatment and/or psychotherapy. ☐ Consider the use of involuntary outpatient commitment, use of assertive community treatment, or other home-based services. Post Discharge ☐ 1 week after discharge via phone or a scheduled meeting, review all of the above. Confirm that an outpatient treatment connection has occurred. If it has not occurred, facilitate this as soon as possible.
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Table 5 Qualitative comments Topic
Responses
Situation Awareness and Creating “Not good that so many of us did not a Safe Environment; Deknow how to describe the specific escalation Training; Violence locations of our offices.” “The Safety Discharge Planning verbal intervention for the behavioral phases were really helpful… we need more time for this session. “It would be nice to use role-plays of our own patients.” “You might want to add some better videos.” “It’s a bit alarming and frightening that outpatients might become violent.” “I have never seen or used a violence discharge checklist. Thanks.” “Too much emphasis on violence…there are other things that are more important.” Violence Risk Assessment “Never used such a detailed clinical Training assessment…helpful.” “Weird that we use suicide assessment tools and have never used a violence risk assessment tool.” Legal Issues and Violence “Heard about this before.” I didn’t know [Colorado] was not a duty to protect state.” “The review of the commitment laws was not necessary…heard this before.” “Shots Fired on Campus” Video “Engrossing” and “Scary,” “I never and Discussion even considered how to manage an active shooter.” Violence Threat Simulation 2011 “Didn’t think a simulation would be Video and Discussion so intense.” “Gives me a real feel of the simulation…not sure I want to do this.” “Now I get why so many residents (last year) were talking about this.”
(HIPPA 1996), which “permits contact with collateral informants without the patient’s consent.”
Violence Threat Simulation Exercises 2011 and 2012 Using Survey Monkey [17], we formally assessed the results of the 2011 and 2012 violence threat simulation exercise. In 2011, we used three scenarios in the threat exercises: (1) distant phone threat to a clinician, (2) patient exhibits escalating violent behaviors leading to an active shooter, and (3) hostage situation with adults leading to an active shooter. In 2012, we utilized three different scenarios: (1) distant threat via multiple phone calls, (2) an aggressive patient progressing to a hostage situation with children, and (3) bomb in the clinic.
Survey ratings from both simulation exercises were similar across 2 years. In 2011 and 2012, we had 67 and 60 participants, respectively, in the simulated exercises with survey response rates of 76 and 86 %, respectively. In 2011 and 2012, respondents reported that the simulation was very helpful/somewhat helpful (90 and 88 %, respectively). Respondents reported feeling much better/better prepared to deal with a violent event (86 and 82 %, respectively). In 2011 and 2012, most reported no post-simulation symptoms (72 and 80 %, respectively). In 2011 and 2012, 20 and 16 %, respectively, suffered mild symptoms while 6 and 0 %, respectively, reported significant post-event symptoms. In 2011, symptoms reported by 13/51 survey respondents included anxiety, sleep disturbance, increase work safety concerns, and worries related to past traumas. We do not know why in 2012, 8/52 survey respondents did not answer our survey questions about specific post-event symptoms. In 2011, 25/51 participants offered written comments; 23/ 25 of the written comments were positive. A sampling of positive comments included the following: (a) “The exercise was invaluable.” (b) “Should be mandatory for all staff.” and (c) “It forced us to think about difficult things that were important, that we would not ordinarily consider.” One negative comment was: “Provided no extra benefit then if it was just a walk-through.” A neutral helpful comment was: “It would have been beneficial to have more time to discuss feelings around the drill and the threat.” In 2012, 46/56 participants offered written comments; 36/ 46 of the comments were positive. A sample of positive comments include the following: (a) “The debriefing was incredibly helpful in processing reactions and illuminating safety needs.” (b) “As a police officer, I felt it was very productive. We were able to identify many coordination issues that need to be addressed.” (c) “Helpful. I am more aware of not being prepared.” Negative comments included the following: (a) “I actually feel less safe in this clinic now that I know how people around me are likely to react to a gunman taking hostages.” (b) “The group feedback was overly critical of participants actions…this is a simulation and an opportunity to make mistakes.” A neutral helpful comment was: “Could use more time in debriefing discussions.”
Discussion We began development of this violence prevention quality and safety performance improvement curriculum/program in 2010 following the “Virginia Tech” and “Tucson” shootings. Coincidentally, exactly 1 week after our implementation of our first 2011 training, a patient made a phone threat “to come to the clinic and shoot everybody with my M16.” This serious threat resulted in a police lock-down and partial 2-day clinic closure. Thankfully,
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this event concluded with no injuries and an arrest of the patient. Staff conveyed gratitude for the training they had just received the week before, and residents/staff requested annual continuation of the program. Base on 2011 and 2012 data, we learned the following: (a) the violence threat simulation exercise is the most effective way to get all residents signed up for the mass communication registry/alerts and to have them program emergency numbers into the speed dials on their cell/office phones. (b) the de-escalation training needs more time than we budgeted and could be improved by choosing better videos and incorporating role-plays using resident’s cases of aggressive patients. We will make these changes in the future. (c) since many participants asked for copies of the violence discharge checklist, we decided to build this checklist document into our EHR. (d) as part of our regular outpatient chart review process (not part of this curriculum), we decided to examine the extent to which clinicians were using the VASA risk assessment scale, which we had also built into our EHR. One month after the completion of the 2012 curriculum, we randomly reviewed 10 new intakes completed by our PGY 3 residents and found that 8/10 electronic charts intakes reviewed had documented violence risk using the VASA scale. (e) participants were most knowledgeable about the major legal issues facing clinicians who treat violent patients. It will be useful to emphasize the relationship between the “duty-to-warn” and “duty-to-protect” standards and the details of HIPPA confidentiality exemption rule. We can decrease time spent on commitment laws. (f) shots fired on campus and the 2011 violence threat simulation video evoked large emotional responses leading to important discussions about managing a shooter, a hostage situation, and stimulated further discussions about the Columbine, Tucson, Aurora, and Newtown shootings. A significant limitation in our ability to assess the first 7 of the 8 program elements was our reliance on qualitative comments that were retrospectively obtained from diverse sources and from a limited sample of participants. In the future, we will adopt a systematic prospective program evaluation of all participants. The qualitative information we obtained is subject to reporting bias and likely more positive, less specific, and less reliable than we would have preferred. Despite this limitation, we felt it beneficial to report the available information. In contrast, the survey data from the 2011/2012 violence threat simulation exercises provides more objective quantitative as well as qualitative information about this aspect of our program. Survey respondents were largely positive about the violence threat simulation exercise. Although most felt better prepared to deal with a violent episode, we do not know whether they’re actually better prepared to handle such events. Participants were minimally traumatized by the simulation exercise. Some suffered mild symptoms, including anxiety, sleep disturbance, and worries
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related to past memories of trauma lasting for a few days. We hypothesize that the few participants, who expressed increased work safety concerns, were previously in denial about the risk of outpatient violence, and because of the simulation, suddenly recognized they were less safe than they thought. It is unclear why 8 (16 %) of 2012 respondents who reported post-event symptoms did not detail their specific symptoms. We speculate that the 2012 prediscussion about trauma risks during the 2011 violence threat simulation video/discussion reduced the number of potential participants with prior trauma histories who had actually signed up to take part in the simulations. A month after each violence threat simulated exercise, we met with the Police Emergency Preparedness Group to review their report and suggestions. They suggested that we continue annual updates/revisions of our scenarios and communication and evacuation plan and emphasized the need for annual practice with our leadership team. This group also emphasized the value of a joint police-clinician leadership team, during an event, for communication and evacuation planning. They have asked our event leaders to delegate more of the various communication and evacuation tasks to other staff that can make sure everyone is notified and/or evacuated as necessary. From review of the videos of the debriefings and comments we received, we recognize the need to schedule additional time and freer discussions during the violence threat simulated exercise debriefings. Accordingly, in the future, we will schedule 45-min debriefings. As a result of offering this curriculum/program, we have made additional changes each year including (a) adding risk assessment tools and updating the safety discharge checklist in our EHR; (b) installing and training staff on the use of additional panic buttons in offices, hallways, and bathrooms; (c) modernizing and extending the availability of the on-demand computer video surveillance system used by office staff and leadership; (d) expanding the reach of the public address system to make sure it can be heard everywhere throughout the clinic; and (e) fixing additional doors that incorrectly opened into offices and blocked safe exit for patients, residents, or staff. Overall, the largely positive responses to this annual curriculum and lessons learned have encouraged us to continue annual training.
Conclusions We developed a comprehensive quality and safety performance improvement curriculum/program in an outpatient setting designed to address eight of the most relevant domains of outpatient violence safety prevention. Since actual violent episodes in our psychiatric outpatient settings are relatively rare occurrences (three to four episodes per year out of
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11,000–12,000 annual patient visits), it is not possible to conclusively demonstrate that we have actually prevented violence from occurring in our outpatient setting. Nevertheless, following each of 2 years of the curriculum and training exercises, residents and staff both report feeling better equipped to deal with aggressive or threatening patients and violent situations or events. We welcome feedback from others regarding adaptations of this program, and we are happy to share the educational materials we’ve developed and field-tested. Implications for Educators • Teaching verbal de-escalation techniques is both practical and improves psychiatric resident and staff feeling of safety in an outpatient setting. • Education in the use of interviewing techniques, clinical violence assessment, and use of violence risk assessment tools may improve clinical judgments and documentation about imminent violence risk. • Teaching use of a “violence safety discharge plan” and incorporating it into the electronic health record is likely beneficial in reducing postdischarge readmission, may reduce violence, and improves documentation of a violence prevention plan. • Teaching via violence threat simulation exercises is practical and is a major experiential teaching tool for facilitating violence prevention in an outpatient clinic environment.
Implications for Academic Leaders • There is a growing need for psychiatric residents’ education and training in violence prevention in an outpatient setting. • Violence prevention in a psychiatric outpatient setting begins by analyzing the safety of your outpatient environments. • It is feasible to develop a low-cost comprehensive educational outpatient violence prevention program for a department, hospital, or for psychiatric/medical outpatient services. • Joint development and training (using violence prevention threat simulation exercises with psychiatric leadership and police) leads to improved cooperation with police, a safer outpatient environment, and leads to both psychiatric residents and staff to feel safer in the outpatient setting.
Acknowledgment This prevention program and material were presented as a workshop at the Association for Academic Psychiatry Meeting in Charleston SC Oct 16–19, 2013. We would like to thank the University of Colorado Police Department for their participation in the development of this program. Disclosure The author states that there are no conflicts of interest in the development of this performance improvement curriculum/program.
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COLUMN: EDUCATIONAL RESOURCE
Violence Prevention Education Program for Psychiatric Outpatient Departments Robert E. Feinstein
Received: 29 December 2013 / Accepted: 2 May 2014 / Published online: 25 July 2014 # Academic Psychiatry 2014
Abstract Objective Approximately 40 % of psychiatrists and up to 64 % of psychiatric residents have been physically assaulted. Ranges of 72–96 % of psychiatric residents in various studies have been verbally threatened. As violence risk occurs in outpatient settings, our department developed a quality and safety curriculum designed to prepare psychiatric residents and staff to optimally respond to aggressive outpatients and violence threats or events. Methods In 2011 and 2012, we offered an 8-part violence prevention performance improvement curriculum/program including (1) situational awareness/creating a safe environment; (2) violence de-escalation training; (3) violence risk assessment training, use of risk assessment tools, and medical record documentation; (4) violence safety discharge planning; (5) legal issues and violence; (6) “shots fired on campus” video/ discussion; (7) “2011 violence threat simulation” video/ discussion; and (8) violence threat simulation exercise. This program was offered to approximately 60 psychiatric residents/staff in each year. Results We obtained qualitative comments about the entire program and data from 2 years of post-event surveys on the usefulness of the “violence threat simulation exercise.” The large majority of comments about program elements 1 to 7 were positive. In 2011 and 2012, respectively, 76 and 86 % of participants responded to a post-event survey of the violence threat simulation exercise; 90 and 88 % of participants, respectively, reported the simulation to be very helpful/
Electronic supplementary material The online version of this article (doi:10.1007/s40596-014-0160-5) contains supplementary material, which is available to authorized users. R. E. Feinstein (*) Department of Psychiatry, Colorado School of Medicine, Aurora, CO, USA e-mail: [email protected]
somewhat helpful; and 86 and 82 % of participants, respectively, reported feeling much better/better prepared to deal with a violent event. Although some participants experienced anxiety, sleep disturbances, increase in work safety concerns, and/or traumatic memories, the majority reported no post-simulation symptoms (72 and 80 %, respectively). Conclusions Although we are unable to demonstrate that this program effectively prevents violence, the overall positive response from participants encourages us to continue developing our quality and safety program and to offer our easily reproducible and modifiable curriculum to others.
Keywords Curriculum development . Violence prevention education and training
The need to prevent violent occurrences in outpatient psychiatric settings is a largely under-recognized problem. In a recent review [1], 100 % of nurses and 24–57 % of physicians in general hospital settings, as documented in multiple studies [1], were annually experiencing aggression or violence from patients. Of all health care workers, 9–25 % as documented in multiple studies [1] experienced verbal aggression. The average rate of reported assault of surveyed psychiatrists is 40 % [2]. The range of percentage of psychiatric residents who report physical assaults is 19–64 % as documented in multiple studies [2]. Multiple studies [1] also show ranges of 72–96 % of residents who have been verbally threatened. Threats, aggression, and violence most frequently occur in high volume patient areas, such as emergency rooms, psychiatric services, geriatric services, and hospital waiting areas [3]. According to University of Colorado Police data, 10 deaths/hostage situations occurred in our state’s health-care facilities between 1987 and 2012. In 2011 and 2012, two serious violent threat
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situations occurred in our own outpatient department that has led to temporary closures of the clinic. While residency training programs provide lectures and training in limited aspects of violence prevention, few offer a comprehensive educational approach for an outpatient setting. This paper describes a unique quality and safety performance and improvement violence prevention curriculum/ program designed for psychiatric residents, staff, and faculty. The Quality Projects Review Board of the Colorado School of Medicine and our Maintenance of Certification Portfolio Approval Program (MOCPAP) have accepted this curriculum/ program as both a quality and safety project and a Maintenance of Certification Part IV Program.
Methods In 2011–2012, we developed and implemented an 8-part outpatient violence prevention curriculum/program for psychiatric residents, staff, and faculty. This quality and safety performance improvement project was developed after several years during which our outpatient clinicians were being threatened by aggressive patients. We have delivered this curriculum/program in 11 h of seminars, which are casebased, interactive, practical experiential, and utilize scenariobased training. See Table 1 for a summary of the curriculum and methods used for teaching. Situation Awareness/Creating a Safe Environment (1-h Session) Conducted in a classroom, and then followed by a walkthrough of our outpatient department, the session covers two elements: (1) Review of the safety features in the outpatient environment. This consists of (a) teaching the use of waiting room and semiprivate interviewing spaces as initial locations for screening potentially intoxicated or violent patients; (b) observe the safety setups required for each resident’s office; (c) walk traffic paths to all exits; and (d) demonstrate use of hallway and office panic buttons, the public address system, and the use of our video surveillance system. We test residents on their ability to describe the exact location of their offices (the first piece of critical information needed when calling for help); (2) Review of outpatient emergency communication plans. This component requires all residents and staff to (a) enroll in our system to receive mass emergency communication alerts via cell phones and e-mails; (b) programming emergency police/security phone numbers into speed dials on their cell/office phones; and (c) receive and study our communication plans, call down list, and summary of this plan on our emergency preparedness information cards, which must be attached to each person’s photo identification card.
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Violence De-escalation Training (1-h Session) Many residency programs offer training on verbal deescalation techniques (e.g., those disseminated by the Crisis Prevention Institute [4]). Since using external resources for trainings can be expensive and time consuming, we developed a 1-h class utilizing role-plays and videos, during which residents practice recognition and interventions for six phases of a violent episode as detailed elsewhere [5–7]. A review of these six phases is also available in supplementary online materials. Violence Risk Assessment Training, Use of Risk Assessment Tools, and Medical Record Documentation (1-h Session) This case-based teaching session focuses on four topics: (1) guidelines for interviewing a violent patient, (see Table 2); (2) clinical assessment of violence risk [8]; and (3) use of violence risk assessment tools (see Tables 3 and 4) practice documenting violence risk. Violence prevention interviewing and history taking are accomplished through case-based teaching and is described elsewhere [6, 7]. We emphasize and practice with a case, using a clinical assessment of imminent violence risk [6–8] which includes (a) clinical assessment of current violent ideation, (b) recent and past history of violence, (c) comorbid medical/psychiatric conditions associated with violence, (d) current and past substance use, (e) assessment of the patient’s support network, (f) assessing the patient’s ability to cooperate with current and proposed treatment, and (g) subjective responses to the interview [6–8]. While clinical assessment of violence risk is essential, judgments of risk can be systematized and enhanced by utilizing standardized violence risk assessment tools, which, by promoting thoroughness, offer better opportunities for improving outcomes. Use of risk assessment tools also serve as part of a mitigating strategy against malpractice lawsuits. Via case-based teaching, clinicians practice the use of the violence and suicide assessment scale (VASA) [9] and the modified overt aggression scale (MOAS) [10]. They learn how to use these tools and document their results in our electronic health record (EHR). We also review the use of other standardized violence risk assessment scales as described in Table 3. Outpatient residents are required to use a risk assessment tool on all intakes and whenever the specter of potential violence has been raised. Violence Safety Discharge Planning (1-h Session) Effective discharge planning from the hospital, emergency departments, or outpatient clinics leads to lower readmission rates for psychiatric patients [11–13]. To
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Table 1 Summary of eight modules and core teachings methods Pretest of all eight modules (see online supplemental materials) I. Situational awareness/creating a safe environment ❖ Each staff member must be able to describe the exact location of his/her office. ❖ Organize an all-staff clinic walk-through to discuss the outpatient environment including the following: • Use the waiting room and semiprivate interviewing spaces, safety of clinic offices, location of all exits, review use of panic buttons, public address system, and video surveillance system ❖ Implement outpatient communication plan • Enroll in a mass communication system for emergency alerts • All should program security/police on office/cell phone speed dials • Review use of the event leadership team and the call down list • Review use of call-in information line • Review evacuation plan • Review what to do in event of an active shooter situation • Review/attach emergency preparedness card information to photo ID II. Violence de-escalation training ❖ Teach six phases of a violent episode: (1) observation, (2) psychomotor, (3) early verbal, (4) late verbal phases, (5) violent episode, and (6) post-violent episode and relevant verbal interventions for each of the phases. Pedagogy: mini-lecture, role-plays, and videos III. Violence risk assessment training, use of risk assessment tools, and medical record documentation ❖ Discuss guidelines for interviewing a violent patient (Table 1), 10-part clinical assessment of violence risk, use of VASA and MOAS ❖ Practice documentation of violence risk and use of risk assessment tools in the electronic health record (EHR) Pedagogy: mini-lecture, case-based teaching. EHR demonstration and practice IV. Violence safety discharge planning checklist ❖ Review the elements of safety discharge planning Pedagogy: case-based teaching, use the safety discharge checklist (Table 3) V. Legal issues and violence ❖ Discuss/review Tarasoff 1 and 2, relevant state laws, confidentiality/HIPPA laws, laws for voluntary/involuntary commitment Pedagogy: mini-lecture, case-based teaching VI. “Shots fired on campus” video/discussion ❖ Show video and discuss/review the safety strategies of getting out, sheltering in, helping others, and taking out an active shooter Pedagogy: video education, mini-lecture, group discussion VII. 2011 Violence threat simulation video/discussion ❖ Show 15-min video of a prior threat simulation exercise as stimulus for discussion of the benefits and risks, and used as an opportunity to obtain voluntarily consent to participate in an upcoming live simulation Pedagogy: video education, mini-lecture, group discussion VIII. Violence threat simulation exercise ❖ This 4-h experiential simulated violence threat exercise includes (1) review of the safety rules for the exercise, (2) verbally administer a group quiz reviewing all of the prior seven elements of this program, and (3) participation in two or three different simulation exercises and debriefings and summarize what was learned Pedagogy: group quiz, experiential learning, group discussion, min-lectures Posttest of all eight modules (see online supplementary materials)
facilitate patient connections to needed outpatient services and mitigate re-occurrence of violence after discharge, we use a single case-based teaching session, in which residents roleplay a case using our standardized violence dischargeplanning checklist (see Table 4). Residents are expected to use this checklist with at least one appropriate patient during the first month of their outpatient rotation.
Legal Issues and Violence (1-h Session) Through case-based teaching we review Tarasoff 1 and 2 [14], our own state laws for “duty to warn” and “duty to protect,” our state commitment laws, and confidentiality requirements when working with violent patients including the Health Insurance Portability Act (HIPPA) exemption rule [15].
642 Table 2 Guidelines for interviewing a violent patient • Interview angry or violent patients in a safe environment • Staff, security, or police should be nearby to intervene, as needed • Establish a working alliance in an effort to better enable patient to accept help and begin finding alternative solutions to hurting others • Focus on recent crisis (e.g., “Why do you think you’re feeling angry/ violent now?) • Identify stressor(s) that have immediately precipitated aggressive/ violent symptoms • Explore the meaning of present violent symptoms and how they’ve evolved over the past 6 weeks • Develop the time line of recent events contributing to the violence • Explore the relationship between past violence and present symptoms • Address patient’s efforts to minimize their difficulties and obscure their intentions • Obtain collateral information from family, friends and the treating providers, past medical records, police, etc. • Monitor common reactions (counter-transferences) to violent patients who are affecting your judgments • Direct the focus of the interview toward risk assessment, treatment, and prevention
“Shots Fired on Campus” Video/Discussion (1-h Session) Jointly taught by police and faculty, residents view and discuss a 15-min video, “Shots Fired on Campus” [16], which depicts what to do in case of a shooter or hostage situation. The video emphasizes how to “get out, shelter in, help out, or take out” an active shooter. We also review previous incidents that occurred in our outpatient clinic.
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with adults, (e) hostage situation with children, and (f) bomb threat. (See supplementary materials we use for the development of these simulations.) These simulated exercises provide experiential training for residents, faculty, staff, and police and are held during a time when the outpatient clinic is closed. We use actors, volunteers, and police to stage and execute three different scenarios per year. Our annual groups of approximately 60 participants have no prior knowledge of the scenarios they will encounter. The exercise has two parts:
Part 1: Safety Review/Violence Prevention Quiz (1-h) We begin with a lunch orientation, where participants register and don appropriately colored T-shirts, identifying them in the simulation either as patients, families, observers, or police. We utilize actor(s) role playing patient/family members, police actors playing patients or assailants, and members of the University Police force who participate in this exercise for their own training. The police review the safety rules of the simulation and emphasize the “absolutely no physical contact rule.” Faculty administers a 35-min group quiz (see supplementary materials) reviewing material previously taught over the entire 7-h prevention program.
Part 2: Three 1-h Simulation Exercise (20–30-min Scenarios and 30–45-min Debriefings)
Violence Threat Simulation Exercise (4 h or ½day of Clinic Time)
Our scenarios are designed to involve multiple participants as in real-life group occurrences. They test participants’ abilities to manage aggressive patients and violent events and test the capabilities of our threat leadership team and the effectiveness of our communication and evacuation plans. Participants receive mass emergency alerts with directions about the simulated threat and are obliged to form a leadership team to manage the event. Some gain experience utilizing our safety systems (e.g., panic buttons, public address system, video surveillance, working with police). Participants may manage a threatening/aggressive/or violent patient, or an agitated family, while others may help or evacuate injured/disabled patients, or manage children/families attending our clinic.
This violence threat simulation exercise has been an annual event since 2011. Faculty and our University Police Preparedness Group jointly plan, deliver, and assess each annual event. To date, we have developed and utilized six different scenarios: (a) distant telephone threat, (b) a patient verbally escalating toward violence, (c) active shooter, (d) hostage situation
The Debriefings After each scenario, the police and faculty co-facilitate a 30–45-min large group debriefing and discussion, which we video. We review what happened during each scenario and learn what did and did not work. We compile a list of problematic processes or safety concerns for future amelioration.
2011 Violence Threat Simulation Video/Discussion (1-h Session) Residents view and discuss a 15-min video we made of the 2011 violence threat simulation exercise. We discuss (a) the intensity and realism of a simulated exercise, (b) the benefits of the program and the risks of developing traumatic symptoms, and (c) ask residents/staff to sign a voluntary consent to participate in an upcoming simulation.
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Table 3 Violence risk assessment tools Risk assessment tools
Patient population
Identifies risk factors
Measures risk factors
Combines risk factor
Produces a final violence risk estimate
Clinical judgments for violence Standard list of violence risk factors Historical clinical risk (HCR-20) [18]
All All Clinician administered general psychiatric patients Clinician administered acute psychiatric patients (C0VR) offenders (LSI)
Some Yes Yes
No No Yes
Yes No No
No No No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Classification of violence risk (COVR) [19] Level of service inventory (LSI) [18] Violence risk appraisal guide [20] Violence and suicide assessment scale (VASA) [9]
Clinician administered mentally Il offenders forensic Clinician administered general psychiatric patients
Post-Simulation Follow-up Several days after the violence threat simulation exercise, we release an online post-event survey, available for 10 days, to determine the usefulness of the simulation. One month later, the police and outpatient leadership analyze these results together, with the addition of written recommendations prepared by our Police Emergency Preparedness Group.
numbers into their cells phones during or immediately after the simulated exercise. Several residents commented they had little prior knowledge of violence risk assessment tools (see Table 3). No residents reported knowing how to use the modified overt aggression scale (MOAS) or the violence and suicide assessment scale (VASA) already available in our EHR. Residents were aware of confidentiality requirements if a danger to self/others existed but were not aware of the Health Insurance Portability and Accountability Act Exemption
Results In 2011 and 2012, we collected qualitative comments and some quantitative data from diverse sources including our residency course evaluation forms, direct participant questioning, and review of comments made when sessions were recorded by video. The author combined and sorted 51 qualitative comments into three groups: positive, neutral, and negative comments. Examples of the most positive and most negative comments and useful neutral comments are presented in Table 5. We also collected qualitative and quantitative data from an online survey evaluating the violence threat simulation exercise. One week after completion of all seven-curriculum components (excluding the violence threat simulation exercise), we checked the electronic registry for mass communications to see how many residents had signed up to receive emergency alerts. Approximately half of the residents were registered to receive alerts. Via direct questioning of a total of 2 years of 127 participants (at the check-in for the simulated exercises during 2011 and 2012), we determined that approximately 2/3 of the participants had not programmed emergency police/ security telephone numbers into the speed dials on their cell phones. One week after the violence threat simulation exercise, we again checked the registry and queried each resident. We found that 100 % of residents had enrolled in mass communication alerts and had programmed emergency phone
Table 4 Violence safety discharge checklist Prior to discharge ☐ Make sure the patient’s immediate discharge environment is safe, without weapons or other means to hurt others ☐ Review with the patient any current/new stressors that might precipitate violence ☐ Review possible early warning signs of increasing violence risk (e.g., substance use or isolation etc.) ☐ Review the patient’s coping strategies to diffuse their dangerous impulses (e.g., use of relaxation techniques, exercise, distraction, etc.) ☐ Review all members of the patient’s support network (e.g., friends, family, place of worship, etc.) and relevant contact information of people the patient can call for help. ☐ Review the use of a 24-hour crisis hotline ☐ Review the use of medications to control violent symptoms ☐ Review the needs and detailed arrangements for follow-up care including the contact information of specific mental health professionals or programs (e.g., alcoholic anonymous) to be contacted for treatment and/or psychotherapy. ☐ Consider the use of involuntary outpatient commitment, use of assertive community treatment, or other home-based services. Post Discharge ☐ 1 week after discharge via phone or a scheduled meeting, review all of the above. Confirm that an outpatient treatment connection has occurred. If it has not occurred, facilitate this as soon as possible.
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Table 5 Qualitative comments Topic
Responses
Situation Awareness and Creating “Not good that so many of us did not a Safe Environment; Deknow how to describe the specific escalation Training; Violence locations of our offices.” “The Safety Discharge Planning verbal intervention for the behavioral phases were really helpful… we need more time for this session. “It would be nice to use role-plays of our own patients.” “You might want to add some better videos.” “It’s a bit alarming and frightening that outpatients might become violent.” “I have never seen or used a violence discharge checklist. Thanks.” “Too much emphasis on violence…there are other things that are more important.” Violence Risk Assessment “Never used such a detailed clinical Training assessment…helpful.” “Weird that we use suicide assessment tools and have never used a violence risk assessment tool.” Legal Issues and Violence “Heard about this before.” I didn’t know [Colorado] was not a duty to protect state.” “The review of the commitment laws was not necessary…heard this before.” “Shots Fired on Campus” Video “Engrossing” and “Scary,” “I never and Discussion even considered how to manage an active shooter.” Violence Threat Simulation 2011 “Didn’t think a simulation would be Video and Discussion so intense.” “Gives me a real feel of the simulation…not sure I want to do this.” “Now I get why so many residents (last year) were talking about this.”
(HIPPA 1996), which “permits contact with collateral informants without the patient’s consent.”
Violence Threat Simulation Exercises 2011 and 2012 Using Survey Monkey [17], we formally assessed the results of the 2011 and 2012 violence threat simulation exercise. In 2011, we used three scenarios in the threat exercises: (1) distant phone threat to a clinician, (2) patient exhibits escalating violent behaviors leading to an active shooter, and (3) hostage situation with adults leading to an active shooter. In 2012, we utilized three different scenarios: (1) distant threat via multiple phone calls, (2) an aggressive patient progressing to a hostage situation with children, and (3) bomb in the clinic.
Survey ratings from both simulation exercises were similar across 2 years. In 2011 and 2012, we had 67 and 60 participants, respectively, in the simulated exercises with survey response rates of 76 and 86 %, respectively. In 2011 and 2012, respondents reported that the simulation was very helpful/somewhat helpful (90 and 88 %, respectively). Respondents reported feeling much better/better prepared to deal with a violent event (86 and 82 %, respectively). In 2011 and 2012, most reported no post-simulation symptoms (72 and 80 %, respectively). In 2011 and 2012, 20 and 16 %, respectively, suffered mild symptoms while 6 and 0 %, respectively, reported significant post-event symptoms. In 2011, symptoms reported by 13/51 survey respondents included anxiety, sleep disturbance, increase work safety concerns, and worries related to past traumas. We do not know why in 2012, 8/52 survey respondents did not answer our survey questions about specific post-event symptoms. In 2011, 25/51 participants offered written comments; 23/ 25 of the written comments were positive. A sampling of positive comments included the following: (a) “The exercise was invaluable.” (b) “Should be mandatory for all staff.” and (c) “It forced us to think about difficult things that were important, that we would not ordinarily consider.” One negative comment was: “Provided no extra benefit then if it was just a walk-through.” A neutral helpful comment was: “It would have been beneficial to have more time to discuss feelings around the drill and the threat.” In 2012, 46/56 participants offered written comments; 36/ 46 of the comments were positive. A sample of positive comments include the following: (a) “The debriefing was incredibly helpful in processing reactions and illuminating safety needs.” (b) “As a police officer, I felt it was very productive. We were able to identify many coordination issues that need to be addressed.” (c) “Helpful. I am more aware of not being prepared.” Negative comments included the following: (a) “I actually feel less safe in this clinic now that I know how people around me are likely to react to a gunman taking hostages.” (b) “The group feedback was overly critical of participants actions…this is a simulation and an opportunity to make mistakes.” A neutral helpful comment was: “Could use more time in debriefing discussions.”
Discussion We began development of this violence prevention quality and safety performance improvement curriculum/program in 2010 following the “Virginia Tech” and “Tucson” shootings. Coincidentally, exactly 1 week after our implementation of our first 2011 training, a patient made a phone threat “to come to the clinic and shoot everybody with my M16.” This serious threat resulted in a police lock-down and partial 2-day clinic closure. Thankfully,
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this event concluded with no injuries and an arrest of the patient. Staff conveyed gratitude for the training they had just received the week before, and residents/staff requested annual continuation of the program. Base on 2011 and 2012 data, we learned the following: (a) the violence threat simulation exercise is the most effective way to get all residents signed up for the mass communication registry/alerts and to have them program emergency numbers into the speed dials on their cell/office phones. (b) the de-escalation training needs more time than we budgeted and could be improved by choosing better videos and incorporating role-plays using resident’s cases of aggressive patients. We will make these changes in the future. (c) since many participants asked for copies of the violence discharge checklist, we decided to build this checklist document into our EHR. (d) as part of our regular outpatient chart review process (not part of this curriculum), we decided to examine the extent to which clinicians were using the VASA risk assessment scale, which we had also built into our EHR. One month after the completion of the 2012 curriculum, we randomly reviewed 10 new intakes completed by our PGY 3 residents and found that 8/10 electronic charts intakes reviewed had documented violence risk using the VASA scale. (e) participants were most knowledgeable about the major legal issues facing clinicians who treat violent patients. It will be useful to emphasize the relationship between the “duty-to-warn” and “duty-to-protect” standards and the details of HIPPA confidentiality exemption rule. We can decrease time spent on commitment laws. (f) shots fired on campus and the 2011 violence threat simulation video evoked large emotional responses leading to important discussions about managing a shooter, a hostage situation, and stimulated further discussions about the Columbine, Tucson, Aurora, and Newtown shootings. A significant limitation in our ability to assess the first 7 of the 8 program elements was our reliance on qualitative comments that were retrospectively obtained from diverse sources and from a limited sample of participants. In the future, we will adopt a systematic prospective program evaluation of all participants. The qualitative information we obtained is subject to reporting bias and likely more positive, less specific, and less reliable than we would have preferred. Despite this limitation, we felt it beneficial to report the available information. In contrast, the survey data from the 2011/2012 violence threat simulation exercises provides more objective quantitative as well as qualitative information about this aspect of our program. Survey respondents were largely positive about the violence threat simulation exercise. Although most felt better prepared to deal with a violent episode, we do not know whether they’re actually better prepared to handle such events. Participants were minimally traumatized by the simulation exercise. Some suffered mild symptoms, including anxiety, sleep disturbance, and worries
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related to past memories of trauma lasting for a few days. We hypothesize that the few participants, who expressed increased work safety concerns, were previously in denial about the risk of outpatient violence, and because of the simulation, suddenly recognized they were less safe than they thought. It is unclear why 8 (16 %) of 2012 respondents who reported post-event symptoms did not detail their specific symptoms. We speculate that the 2012 prediscussion about trauma risks during the 2011 violence threat simulation video/discussion reduced the number of potential participants with prior trauma histories who had actually signed up to take part in the simulations. A month after each violence threat simulated exercise, we met with the Police Emergency Preparedness Group to review their report and suggestions. They suggested that we continue annual updates/revisions of our scenarios and communication and evacuation plan and emphasized the need for annual practice with our leadership team. This group also emphasized the value of a joint police-clinician leadership team, during an event, for communication and evacuation planning. They have asked our event leaders to delegate more of the various communication and evacuation tasks to other staff that can make sure everyone is notified and/or evacuated as necessary. From review of the videos of the debriefings and comments we received, we recognize the need to schedule additional time and freer discussions during the violence threat simulated exercise debriefings. Accordingly, in the future, we will schedule 45-min debriefings. As a result of offering this curriculum/program, we have made additional changes each year including (a) adding risk assessment tools and updating the safety discharge checklist in our EHR; (b) installing and training staff on the use of additional panic buttons in offices, hallways, and bathrooms; (c) modernizing and extending the availability of the on-demand computer video surveillance system used by office staff and leadership; (d) expanding the reach of the public address system to make sure it can be heard everywhere throughout the clinic; and (e) fixing additional doors that incorrectly opened into offices and blocked safe exit for patients, residents, or staff. Overall, the largely positive responses to this annual curriculum and lessons learned have encouraged us to continue annual training.
Conclusions We developed a comprehensive quality and safety performance improvement curriculum/program in an outpatient setting designed to address eight of the most relevant domains of outpatient violence safety prevention. Since actual violent episodes in our psychiatric outpatient settings are relatively rare occurrences (three to four episodes per year out of
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11,000–12,000 annual patient visits), it is not possible to conclusively demonstrate that we have actually prevented violence from occurring in our outpatient setting. Nevertheless, following each of 2 years of the curriculum and training exercises, residents and staff both report feeling better equipped to deal with aggressive or threatening patients and violent situations or events. We welcome feedback from others regarding adaptations of this program, and we are happy to share the educational materials we’ve developed and field-tested. Implications for Educators • Teaching verbal de-escalation techniques is both practical and improves psychiatric resident and staff feeling of safety in an outpatient setting. • Education in the use of interviewing techniques, clinical violence assessment, and use of violence risk assessment tools may improve clinical judgments and documentation about imminent violence risk. • Teaching use of a “violence safety discharge plan” and incorporating it into the electronic health record is likely beneficial in reducing postdischarge readmission, may reduce violence, and improves documentation of a violence prevention plan. • Teaching via violence threat simulation exercises is practical and is a major experiential teaching tool for facilitating violence prevention in an outpatient clinic environment.
Implications for Academic Leaders • There is a growing need for psychiatric residents’ education and training in violence prevention in an outpatient setting. • Violence prevention in a psychiatric outpatient setting begins by analyzing the safety of your outpatient environments. • It is feasible to develop a low-cost comprehensive educational outpatient violence prevention program for a department, hospital, or for psychiatric/medical outpatient services. • Joint development and training (using violence prevention threat simulation exercises with psychiatric leadership and police) leads to improved cooperation with police, a safer outpatient environment, and leads to both psychiatric residents and staff to feel safer in the outpatient setting.
Acknowledgment This prevention program and material were presented as a workshop at the Association for Academic Psychiatry Meeting in Charleston SC Oct 16–19, 2013. We would like to thank the University of Colorado Police Department for their participation in the development of this program. Disclosure The author states that there are no conflicts of interest in the development of this performance improvement curriculum/program.
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